S AT URDAY, 23T H AGUS T 2014

MORNING REPORT
NEUROLOGIC DEPARTMENT
Patient identity
Name : Mr Su
Age : 65 years old
Sex : Male
Work : Farmer
Address : Lamongan
Examination date : Agust 23th, 2014
ANAMNESIS
Chief Complaint
loss of consciousness
Present illness History
Patient loss of consciousness 5 hour before
admision IGD after fall in bathroom. Seizure 1x,
than conscious and can talk normally and
than unconciousness. Vomiting 1x during a trip
to Emergency room, contain like sputum,
white, half a glass of mineral water.
Headacne before (-)
Previously illnes history
Never like this before
HT (+) since 10 years ago, never taking medication.
DM denial.
Family illnes History
HT dont know
Medicine taking history
-
Social history
Smoker active 2 packs/day
Vital Sign
GCS : 112
Blood pressure : 195/121 mmHg
Heart Rate : 117x /minutes
RR : 26x /minutes
Axilla temperature : 37.8
o
C
Head / neck : an (-), ict (-), cy (-), dys (-)
Thorax : Normal chest form, retraction (-),
Pulmonary
Pulmo : ves/Ves, Rh-/-, Wh -/-
Cor : S1-S2 single, murmur (-), gallop (-)
Abdomen
I : flat
P : soefl, Liver / Splen not palpable.
P : thimpany
A : Bowel sound (+) Normal
Extremity : aie -, warm, dry, CRT < 2
N. I (Olfactorius): SDE
N. II (Opticus) : SDE, pin point, round isokor 2mm/2mm, RC -/-
N. III (Okulomotorius) : SDE
N. IV (Trochlearis) : SDE
N. VI (Abducen) : SDE
N. V (Trigeminus) : SDE
N. VII (Facialis) : SDE
N.VIII (acusticus) : SDE
N. IX (Glossofaringeus) : SDE
N. X (Vagus) : SDE
N. XI (Assesorius) : SDE
N. XII (Hipoglossus) : SDE
Meningeal sign:
Kaku kuduk : -/- brudzinsky 1 :-/-
Kernig : -/-
Kekuatan : sde
Tonus muscle : spastic
Reflek Fisiologis :
BPR : +3/+3 KPR : +3/+3
TPR : +2/+2 APR : +2/+2
Reflek Patologis :
Babinsky: +/+ Hoffman Trommer : + /+
Chaddock: +/+ Gordon : +/ +
Schaefer: +/ + Oppenheim : - / -
sde
CLUE AND CUE
Male, 65 yo
loss of consciousness
seizure
Vomit
History HT, never taking medication
Smoker active 2 packs/day



LABORATORY FINDING
Diffcount : 1/1/92/4/2
Hematocrit : 40.5
Hb : 14.0
LED : 33/54
Leukosit : 18.000
Trombosit : 324.000
Urea : 25 (10-50 mg/dl)
Creatinin serum : 0,8 (0,7-12 mg/dl)
RBS : 142
PT : 10.3 (10.3-16.3 detik)
APTT : 25.0 (24.2-38.2 detik)
SIRIRAJ SCORE
(2.5xkesadaran)+(2xvomit)+(2xheadacne)+0.1(TD
Diastol)-(3xatheroma)
=(2.5X2)+(2X1)+(2X0)+0.1(12.1)-(3X1)-12
= +4
CT SCAN SKULL
THORAX XRAY
Clinical diagnosis
Fisiologic reflek , Patologic reflek (+), vomite, pupil pin point,
GCS 112 (Acute LOC)
Topis diagnosis
A. Cerebri media
Etiologic diagnosis
CVA Bleeding
MONITORING
GCS
Vital sign
PLANNING THERAPHY
IVFD Ringer assering 1500/24 hours
Inj ranitidin 2x50mg
Inj phenytoin 3x100cc
Inj metamizol 3x500mg
Manitol loading 200cc 6x100cc
Pump Nicardipin 3mg/jam TDS <160
Consult: Sp.S
PLANNING EDUCATION
Explain to the patients family about the diagnosis,
etiology, intervention of therapy, complication, and
prognosis.